Matheka et al. Globalization and Health 2013, 9:55 http://www.globalizationandhealth.com/content/9/1/55
RESEARCH
Open Access
Pattern, knowledge and practices of HbA1C testing among diabetic patients in a Kenyan tertiary referral hospital Duncan Mwangangi Matheka1,2*, Jeremiah Munguti Kilonzo3, Cecilia Muvenyi Munguti1 and Peter Waweru Mwangi1
Abstract Background: Glycated haemoglobin (HbA1C) measurement is the currently accepted gold standard biochemical indicator of long-term glycemic control in diabetic patients. The level of knowledge as well as the frequency of use of this test among diabetic patients in Kenya is unknown. The current study aimed to document this among patients attending the diabetes clinic at a national referral hospital in Kenya. Methods: One hundred and ninety eight diabetic patients (59 male and 139 female) attending the outpatient diabetes clinic at the Kenyatta National Hospital were interviewed on their level of knowledge and use of the HbA1C test, as well as their last HbA1C level. The respondent answers were tabulated, analyzed and summarized. The sample mean, standard deviation and percentages were calculated. Results: Of the 198 patients interviewed, 11 (5.6%) had type I diabetes mellitus (DM) while 187 (94.4%) had type II DM. One hundred and thirty four patients (67.7%) had heard of the HbA1C test while 64 patients (32.3%) had never heard of the test. Forty patients (20.2%) had at one point done the test while 158 (79.8%) had never done the test. The mean HbA1C level of the 40 patients who had at any one time done the test was 8.5 ± 1.7%, with more than 90% having HbA1C > 8%. Conclusion: Using self-reported accounts, the current study indicates inadequate knowledge and infrequent testing of HbA1C among diabetic outpatients in Kenya. This lack of knowledge and awareness may lead to increased susceptibility to the development of diabetic complications, and potentially higher healthcare costs among these patients. It is our recommendation that policy makers focus on strategies that address HbA1C test accessibility in Kenya, including financial coverage by the national insurance to access the test in public facilities, so as to effectively monitor and combat DM. Keywords: HbA1C, Glycemic monitoring, Availability, Knowledge awareness and practices (KAP), Diabetes mellitus (DM), NCDs, Kenya, Sub-Saharan Africa
Background Diabetes mellitus (DM) is a chronic debilitating noncommunicable disease (NCD). In 2011, 366 million individuals had DM, a number that is projected to rise to 552 million by 2030, unless preventive interventions are put in place [1]. Approximately 80% of the burden of * Correspondence: [email protected] 1 Department of Medical Physiology, School of Medicine, University of Nairobi, P.O. Box 30197-00100, Nairobi, Kenya 2 Young Professionals Chronic Disease Network, Nairobi, Kenya Full list of author information is available at the end of the article
DM is in the low-and middle-income countries, and it is growing [1]. In one such country (Kenya), the prevalence of DM has risen from 3.3% in 2007 to 4.2% in 2009, with prevalence rates of up to 10% in some regions [1,2]. The HbA1C test is an indicator of average blood glucose concentrations over the preceding three months. It is a well-established biomarker of long-term glucose control and was approved by the World Health Organization (WHO) for the diagnosis of DM and monitoring glycemic control in people with diabetes [3,4]. Higher HbA1C levels (recommended levels should be
© 2013 Matheka et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Matheka et al. Globalization and Health 2013, 9:55 http://www.globalizationandhealth.com/content/9/1/55
maintained at 8%. Discussion We performed the first study of the frequency and knowledge of HbA1C testing among diabetic patients in Kenya. Using a sample of diabetes patients at the KNH, we found that only 20% of patients had ever done at least one HbA1C check. Among those who did the test, the average HbA1C level was high (more than 90% had HbA1C > 8%). Moreover, we found that only 67.7% of patients interviewed had heard of the HbA1C test. Checks
Matheka et al. Globalization and Health 2013, 9:55 http://www.globalizationandhealth.com/content/9/1/55
were few and HbA1C knowledge low in both type I and type II diabetic patients. HbA1C quarterly measurement combined with daily home blood glucose monitoring forms the gold standard of glycemic control in clinical practice [4]. However, HbA1C monitoring is easier said than done, especially in developing countries like Kenya, due to cost constraints [3,4,11]. Currently, HbA1C testing by outpatients in Kenya is paid for by the patient and is not covered by the national insurance. Published reports indicate that the average cost of an HbA1C test in Kenya is US$10 in public health facilities and up to US$25 in private facilities [3]. This cost is prohibitive in a country where 50% of the residents live on less than US$1 a day [11,12] and also contributes to its low availability [4]. The absence of a proper national health insurance plan in Kenya also makes HbA1C financially burdensome. This could explain why a vast majority of our study subjects (80%) had never had the test done. These results are comparable to those of a similar study conducted in Nigeria [13]. Increasing awareness of the test is important. Our study found that a relatively high percentage of diabetes patients had never heard of the test (>30%). One reason for this may be that outpatient HbA1C testing is not part of the package of essential medicines and diagnostics covered by the government through national insurance, and thus is not advertised as being available. This may also be a reflection of the lack of awareness of its utility, as well as the availability of the test among the caregivers coming into contact with the patient. Previous studies have shown that caregivers are the primary sources of information about diabetes to their patients [14]. The relatively low level of awareness of the test as well the low frequencies of testing are noteworthy, particularly since the patient cohort was obtained from a major teaching and referral hospital where one would ordinarily expect cutting edge therapeutic and disease management approaches to be adopted as a matter of course. Further, this is an indication that the situation in lower level health facilities may actually be worse than what is documented in this study. There is a need to carry out studies to document the level of awareness, skill and attitudes among Kenyan health professionals on the HbA1C test in lower level health care facilities and assess existence of relevant training programs initiated to remedy any identified knowledge gaps. Furthermore, a widespread rollout of subsidized or free HbA1C testing in all government health facilities would ensure integration of this test in diabetes management regimens. This is so as to ensure the optimal glycemic control in all patients and hence prevent the development of diabetic complications. The reported high HbA1C levels (8.5 ± 1.7%), among the 40 patients who had undergone testing in our study are indicative of poor glycemic control that often leads to the development of diabetic complications [8,15]. In
Page 3 of 4
these 40 patients with information on their HbA1C level, over 90% had poor glycemic control (HbA1C > 7%). This suggests that poor glycemic control may also be a problem among those not tested. This may be a reflection of the use of treatment regimens or dosages of sub-optimal efficacy and/or poor drug compliance by the patients. It may also reflect a misconception among caregivers that this test should only be used in patients with more serious disease instead of being used in routine management as recommended. Lastly, besides concerns on the reliability of selfreported data by the participants, results from this study suggest that a small proportion of diabetic patients at KNH have received health education regarding HbA1C. There is also a possibility that HbA1C tests may have been done without the knowledge of the patients, and that their results were not discussed with the doctor. Increased patient involvement and proper communication on the part of health care providers, as well as discussion to ensure that the patients understand their management, is critical. With HbA1C approval for glycemic monitoring, health care providers need to educate their patients on its role too [10]. Our future research in this area will focus on patient follow up and outcomes with appropriate HbA1C testing. Moreover, we will focus on studying the patterns of HbA1C testing in each type of DM, since it can be noticed that most patients interviewed in the current study (94.4%) had type II DM.
Conclusion The results of the current study indicate inadequate knowledge and monitoring of blood glucose control among diabetic patients in Kenya using the HbA1C test. This signals a lack of access to care and low public awareness about the test and may lead to increased susceptibility to the development of diabetic complications among these patients. The consequences include increasing healthcare costs in a population facing a double burden of disease. It is our recommendation that policy makers focus on strategies that address HbA1C test accessibility in Kenya, including financial coverage by the national insurance to access the test in public facilities, so as to effectively monitor and combat DM. We also call for streamlining of the healthcare infrastructure and national health insurance towards coverage of outpatient clinic costs. Abbreviations DM: Diabetes mellitus; ERC: Ethics Research Committee; HbA1C: Glycated haemoglobin; KNH: Kenyatta National Hospital; Type I DM: Type 1 diabetes mellitus; Type II DM: Type 2 diabetes mellitus.
Competing interests The authors declare that they have no competing interests.
Matheka et al. Globalization and Health 2013, 9:55 http://www.globalizationandhealth.com/content/9/1/55
Page 4 of 4
Authors’ contributions DMM was responsible for conception, design, data collection, analysis, interpretation and write up of the manuscript; JMK involved in design, data collection, drafting and revision of manuscript; CMM involved in data collection, analysis, and drafting of manuscript; PWM involved in conception, design and critical revision of manuscript. All authors read and approved the final version of the manuscript. Acknowledgements We thank Karen Siegel and Sandeep Kishore for their assistance in reviewing the manuscript. Author details 1 Department of Medical Physiology, School of Medicine, University of Nairobi, P.O. Box 30197-00100, Nairobi, Kenya. 2Young Professionals Chronic Disease Network, Nairobi, Kenya. 3Department of Human Anatomy, School of Medicine, University of Nairobi, Nairobi, Kenya. Received: 11 April 2013 Accepted: 17 October 2013 Published: 5 November 2013 References 1. International Diabetes Federation: IDF diabetes atlas. 5th edition. Belgium: Brussels; 2011. http://www.idf.org/diabetesatlas/news/fifth-edition-release. 2. Dirk LC, Henrik F, Mwaniki DL, Kilonzo B, Tetens I, Boit MK: Prevalence of glucose intolerance and associated risk factors in rural and urban populations of different ethnic groups in Kenya. Diabetes Res Clin Pract 2009, 84:303–310. 3. Karongo C: WHO approved diabetes kit costly for Kenya. http://www.capitalfm. co.ke/news/2011/01/who-approved-diabetes-kit-costly-for-kenya/. 4. Geoff G: Diabetes diagnosis by HbA1C. Afr J Diab Med 2011, 19(1):3. 5. Lind M, Odén A, Fahlén M, Eliasson B: The shape of the metabolic memory of HbA1c: re-analysing the DCCT with respect to time dependent effects. Diabetologia 2010, 53:1093–1098. 6. International diabetes federation (IDF) working group on HbA1c. http://www. idf.org/hba1c-working-group. 7. Kenya national clinic guidelines for management of diabetes mellitus. http:// diabetes-communication.org/wordpress/wp-content/uploads/2012/09/ National-Clinic-Guidelines-for-Management-of-Diabetes-Melitus-Complete.pdf. 8. American Diabetes Association: Standards of medical care in diabetes. Diabetes Care 2011, 34(Suppl 1):S11–S61. 9. Heisler M, Piette JD, Spencer M, Kieffer E, Vijan S: The relationship between knowledge of recent HbA1c values and diabetes care understanding and self-management. Diabetes Care 2005, 28(4):816–822. 10. Otieno CF, Kariuki M, Ng’ang’a L: Quality of glycaemic control in ambulatory diabetics at the out-patient clinic of Kenyatta National Hospital Nairobi. East Afr Med J 2003, 80(8):406–410. 11. Overview on Kenya. http://www.unicef.org/kenya/overview_4616.html. 12. Rhee MK, Cook CB, Dunbar VG, Panayioto RM, Berkowitz KJ, Boyd B, George CD, Lyles RH, El-Kebbi IM, Phillips LS: Limited health care access impairs glycemic control in low income urban African Americans with type 2 diabetes. J Health Care Poor Underserved 2005, 16:734–746. 13. Adenisa OF, Oduniyi AO, Olutunde AO, Ogunlana MO, Ogunkoya, Alalade BA, Otubogun SM, Adenisa AC: Is HbA1C testing in Nigeria only for the rich? Afr J Diab Med 2012, 20(2):47. 14. Rosheim KM, Fowles JB: Where do people with diabetes obtain information about their disease? Diabetes Spectrum 1996, 12(3):136. 15. Rohlfing CL, Wiedmeyer HM, Little RR, England JD, Tennill A, Goldstein DE: Defining the relationship between plasma glucose and HbA (1c): analysis of glucose profiles and HbA (1c) in the diabetes control and complications trial. Diabetes Care 2002, 25:275–278.
Submit your next manuscript to BioMed Central and take full advantage of: • Convenient online submission
doi:10.1186/1744-8603-9-55 Cite this article as: Matheka et al.: Pattern, knowledge and practices of HbA1C testing among diabetic patients in a Kenyan tertiary referral hospital. Globalization and Health 2013 9:55.
• Thorough peer review • No space constraints or color figure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit
RESEARCH
Open Access
Pattern, knowledge and practices of HbA1C testing among diabetic patients in a Kenyan tertiary referral hospital Duncan Mwangangi Matheka1,2*, Jeremiah Munguti Kilonzo3, Cecilia Muvenyi Munguti1 and Peter Waweru Mwangi1
Abstract Background: Glycated haemoglobin (HbA1C) measurement is the currently accepted gold standard biochemical indicator of long-term glycemic control in diabetic patients. The level of knowledge as well as the frequency of use of this test among diabetic patients in Kenya is unknown. The current study aimed to document this among patients attending the diabetes clinic at a national referral hospital in Kenya. Methods: One hundred and ninety eight diabetic patients (59 male and 139 female) attending the outpatient diabetes clinic at the Kenyatta National Hospital were interviewed on their level of knowledge and use of the HbA1C test, as well as their last HbA1C level. The respondent answers were tabulated, analyzed and summarized. The sample mean, standard deviation and percentages were calculated. Results: Of the 198 patients interviewed, 11 (5.6%) had type I diabetes mellitus (DM) while 187 (94.4%) had type II DM. One hundred and thirty four patients (67.7%) had heard of the HbA1C test while 64 patients (32.3%) had never heard of the test. Forty patients (20.2%) had at one point done the test while 158 (79.8%) had never done the test. The mean HbA1C level of the 40 patients who had at any one time done the test was 8.5 ± 1.7%, with more than 90% having HbA1C > 8%. Conclusion: Using self-reported accounts, the current study indicates inadequate knowledge and infrequent testing of HbA1C among diabetic outpatients in Kenya. This lack of knowledge and awareness may lead to increased susceptibility to the development of diabetic complications, and potentially higher healthcare costs among these patients. It is our recommendation that policy makers focus on strategies that address HbA1C test accessibility in Kenya, including financial coverage by the national insurance to access the test in public facilities, so as to effectively monitor and combat DM. Keywords: HbA1C, Glycemic monitoring, Availability, Knowledge awareness and practices (KAP), Diabetes mellitus (DM), NCDs, Kenya, Sub-Saharan Africa
Background Diabetes mellitus (DM) is a chronic debilitating noncommunicable disease (NCD). In 2011, 366 million individuals had DM, a number that is projected to rise to 552 million by 2030, unless preventive interventions are put in place [1]. Approximately 80% of the burden of * Correspondence: [email protected] 1 Department of Medical Physiology, School of Medicine, University of Nairobi, P.O. Box 30197-00100, Nairobi, Kenya 2 Young Professionals Chronic Disease Network, Nairobi, Kenya Full list of author information is available at the end of the article
DM is in the low-and middle-income countries, and it is growing [1]. In one such country (Kenya), the prevalence of DM has risen from 3.3% in 2007 to 4.2% in 2009, with prevalence rates of up to 10% in some regions [1,2]. The HbA1C test is an indicator of average blood glucose concentrations over the preceding three months. It is a well-established biomarker of long-term glucose control and was approved by the World Health Organization (WHO) for the diagnosis of DM and monitoring glycemic control in people with diabetes [3,4]. Higher HbA1C levels (recommended levels should be
© 2013 Matheka et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Matheka et al. Globalization and Health 2013, 9:55 http://www.globalizationandhealth.com/content/9/1/55
maintained at 8%. Discussion We performed the first study of the frequency and knowledge of HbA1C testing among diabetic patients in Kenya. Using a sample of diabetes patients at the KNH, we found that only 20% of patients had ever done at least one HbA1C check. Among those who did the test, the average HbA1C level was high (more than 90% had HbA1C > 8%). Moreover, we found that only 67.7% of patients interviewed had heard of the HbA1C test. Checks
Matheka et al. Globalization and Health 2013, 9:55 http://www.globalizationandhealth.com/content/9/1/55
were few and HbA1C knowledge low in both type I and type II diabetic patients. HbA1C quarterly measurement combined with daily home blood glucose monitoring forms the gold standard of glycemic control in clinical practice [4]. However, HbA1C monitoring is easier said than done, especially in developing countries like Kenya, due to cost constraints [3,4,11]. Currently, HbA1C testing by outpatients in Kenya is paid for by the patient and is not covered by the national insurance. Published reports indicate that the average cost of an HbA1C test in Kenya is US$10 in public health facilities and up to US$25 in private facilities [3]. This cost is prohibitive in a country where 50% of the residents live on less than US$1 a day [11,12] and also contributes to its low availability [4]. The absence of a proper national health insurance plan in Kenya also makes HbA1C financially burdensome. This could explain why a vast majority of our study subjects (80%) had never had the test done. These results are comparable to those of a similar study conducted in Nigeria [13]. Increasing awareness of the test is important. Our study found that a relatively high percentage of diabetes patients had never heard of the test (>30%). One reason for this may be that outpatient HbA1C testing is not part of the package of essential medicines and diagnostics covered by the government through national insurance, and thus is not advertised as being available. This may also be a reflection of the lack of awareness of its utility, as well as the availability of the test among the caregivers coming into contact with the patient. Previous studies have shown that caregivers are the primary sources of information about diabetes to their patients [14]. The relatively low level of awareness of the test as well the low frequencies of testing are noteworthy, particularly since the patient cohort was obtained from a major teaching and referral hospital where one would ordinarily expect cutting edge therapeutic and disease management approaches to be adopted as a matter of course. Further, this is an indication that the situation in lower level health facilities may actually be worse than what is documented in this study. There is a need to carry out studies to document the level of awareness, skill and attitudes among Kenyan health professionals on the HbA1C test in lower level health care facilities and assess existence of relevant training programs initiated to remedy any identified knowledge gaps. Furthermore, a widespread rollout of subsidized or free HbA1C testing in all government health facilities would ensure integration of this test in diabetes management regimens. This is so as to ensure the optimal glycemic control in all patients and hence prevent the development of diabetic complications. The reported high HbA1C levels (8.5 ± 1.7%), among the 40 patients who had undergone testing in our study are indicative of poor glycemic control that often leads to the development of diabetic complications [8,15]. In
Page 3 of 4
these 40 patients with information on their HbA1C level, over 90% had poor glycemic control (HbA1C > 7%). This suggests that poor glycemic control may also be a problem among those not tested. This may be a reflection of the use of treatment regimens or dosages of sub-optimal efficacy and/or poor drug compliance by the patients. It may also reflect a misconception among caregivers that this test should only be used in patients with more serious disease instead of being used in routine management as recommended. Lastly, besides concerns on the reliability of selfreported data by the participants, results from this study suggest that a small proportion of diabetic patients at KNH have received health education regarding HbA1C. There is also a possibility that HbA1C tests may have been done without the knowledge of the patients, and that their results were not discussed with the doctor. Increased patient involvement and proper communication on the part of health care providers, as well as discussion to ensure that the patients understand their management, is critical. With HbA1C approval for glycemic monitoring, health care providers need to educate their patients on its role too [10]. Our future research in this area will focus on patient follow up and outcomes with appropriate HbA1C testing. Moreover, we will focus on studying the patterns of HbA1C testing in each type of DM, since it can be noticed that most patients interviewed in the current study (94.4%) had type II DM.
Conclusion The results of the current study indicate inadequate knowledge and monitoring of blood glucose control among diabetic patients in Kenya using the HbA1C test. This signals a lack of access to care and low public awareness about the test and may lead to increased susceptibility to the development of diabetic complications among these patients. The consequences include increasing healthcare costs in a population facing a double burden of disease. It is our recommendation that policy makers focus on strategies that address HbA1C test accessibility in Kenya, including financial coverage by the national insurance to access the test in public facilities, so as to effectively monitor and combat DM. We also call for streamlining of the healthcare infrastructure and national health insurance towards coverage of outpatient clinic costs. Abbreviations DM: Diabetes mellitus; ERC: Ethics Research Committee; HbA1C: Glycated haemoglobin; KNH: Kenyatta National Hospital; Type I DM: Type 1 diabetes mellitus; Type II DM: Type 2 diabetes mellitus.
Competing interests The authors declare that they have no competing interests.
Matheka et al. Globalization and Health 2013, 9:55 http://www.globalizationandhealth.com/content/9/1/55
Page 4 of 4
Authors’ contributions DMM was responsible for conception, design, data collection, analysis, interpretation and write up of the manuscript; JMK involved in design, data collection, drafting and revision of manuscript; CMM involved in data collection, analysis, and drafting of manuscript; PWM involved in conception, design and critical revision of manuscript. All authors read and approved the final version of the manuscript. Acknowledgements We thank Karen Siegel and Sandeep Kishore for their assistance in reviewing the manuscript. Author details 1 Department of Medical Physiology, School of Medicine, University of Nairobi, P.O. Box 30197-00100, Nairobi, Kenya. 2Young Professionals Chronic Disease Network, Nairobi, Kenya. 3Department of Human Anatomy, School of Medicine, University of Nairobi, Nairobi, Kenya. Received: 11 April 2013 Accepted: 17 October 2013 Published: 5 November 2013 References 1. International Diabetes Federation: IDF diabetes atlas. 5th edition. Belgium: Brussels; 2011. http://www.idf.org/diabetesatlas/news/fifth-edition-release. 2. Dirk LC, Henrik F, Mwaniki DL, Kilonzo B, Tetens I, Boit MK: Prevalence of glucose intolerance and associated risk factors in rural and urban populations of different ethnic groups in Kenya. Diabetes Res Clin Pract 2009, 84:303–310. 3. Karongo C: WHO approved diabetes kit costly for Kenya. http://www.capitalfm. co.ke/news/2011/01/who-approved-diabetes-kit-costly-for-kenya/. 4. Geoff G: Diabetes diagnosis by HbA1C. Afr J Diab Med 2011, 19(1):3. 5. Lind M, Odén A, Fahlén M, Eliasson B: The shape of the metabolic memory of HbA1c: re-analysing the DCCT with respect to time dependent effects. Diabetologia 2010, 53:1093–1098. 6. International diabetes federation (IDF) working group on HbA1c. http://www. idf.org/hba1c-working-group. 7. Kenya national clinic guidelines for management of diabetes mellitus. http:// diabetes-communication.org/wordpress/wp-content/uploads/2012/09/ National-Clinic-Guidelines-for-Management-of-Diabetes-Melitus-Complete.pdf. 8. American Diabetes Association: Standards of medical care in diabetes. Diabetes Care 2011, 34(Suppl 1):S11–S61. 9. Heisler M, Piette JD, Spencer M, Kieffer E, Vijan S: The relationship between knowledge of recent HbA1c values and diabetes care understanding and self-management. Diabetes Care 2005, 28(4):816–822. 10. Otieno CF, Kariuki M, Ng’ang’a L: Quality of glycaemic control in ambulatory diabetics at the out-patient clinic of Kenyatta National Hospital Nairobi. East Afr Med J 2003, 80(8):406–410. 11. Overview on Kenya. http://www.unicef.org/kenya/overview_4616.html. 12. Rhee MK, Cook CB, Dunbar VG, Panayioto RM, Berkowitz KJ, Boyd B, George CD, Lyles RH, El-Kebbi IM, Phillips LS: Limited health care access impairs glycemic control in low income urban African Americans with type 2 diabetes. J Health Care Poor Underserved 2005, 16:734–746. 13. Adenisa OF, Oduniyi AO, Olutunde AO, Ogunlana MO, Ogunkoya, Alalade BA, Otubogun SM, Adenisa AC: Is HbA1C testing in Nigeria only for the rich? Afr J Diab Med 2012, 20(2):47. 14. Rosheim KM, Fowles JB: Where do people with diabetes obtain information about their disease? Diabetes Spectrum 1996, 12(3):136. 15. Rohlfing CL, Wiedmeyer HM, Little RR, England JD, Tennill A, Goldstein DE: Defining the relationship between plasma glucose and HbA (1c): analysis of glucose profiles and HbA (1c) in the diabetes control and complications trial. Diabetes Care 2002, 25:275–278.
Submit your next manuscript to BioMed Central and take full advantage of: • Convenient online submission
doi:10.1186/1744-8603-9-55 Cite this article as: Matheka et al.: Pattern, knowledge and practices of HbA1C testing among diabetic patients in a Kenyan tertiary referral hospital. Globalization and Health 2013 9:55.
• Thorough peer review • No space constraints or color figure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit
